Kimi's first day on Vetoryl

[kimithedachshund]

Hello there

My 13 yo female Kimi started on Vetoryl today. I just found your website yesterday and have called the vet to prepare all Kimi's labs for me. I'll post them up after work tonight late.

Meanwhile her clinical symptoms include excessive drinking/peeing, urinary incontinence, recurrent UTIs (She's on her third straight course of abx with clear urine before discontinuing and symptoms 3 days after cycle), increased appetite (which we never thought was possible), getting into the garbage, loose skin, bloated appearance, Alk. Phos. off the charts, lethargy, weakness (she often stumbles or trembles when she's just standing there).

She weighs 16.5 pounds or 7.5kg and is taking 20mg daily. Having read a bit it seems like it might be better to give 10 mg twice daily.

Either way of course exceeds the 1mg/lb however but given that 5mg caps don't seem t be an option here the only other choice is 1mg/1.65lbs...could that be an effective dose?

The company warns not to split the capsules. Why not? If I could split the contents of a 10 mg capsule I could get pretty darn close to 1mg/kg. The vet says no, the company says no, but no one can tell me why. Splitting 30mg capsules in two would accomplish the same thing and save a ton. I'm not rich and this stuff ain't cheap. Even for a small dog. Only reason I haven't had an ultrasound is financial.

I found a Canadian website (thanks to you guys) that sells compounded T. At least that should be a viable option assuming the Vetoryl trial she's on works out.

Thanks for any help and for creating this site full of great info

[labblab]

Hello and welcome to you and Kimi -- I'm so glad you've found us!

I have only a moment to post, but wanted to say that if Kimi was my own dog, I would go ahead and stick with the 20 mg. to start off. It is a little bit over the 1 mg. per pound formula, but not by a lot.

There are multiple reasons why capsules, in general, should not be opened by a nonprofessional pharmacist and the contents "split." The first is that the loose powder inside the capsule is a combination of active chemical and inactive "filler." When the capsule is given to the patient intact, it is a certainty that the full dose is being given at one time. But if you start messing with the powder, you have no way of separating out the active chemical from the filler so that you know how much of either you are giving in the divided dose. More of the active ingredient could be falling within one dose, and very little in the other.

Also, the way in which a chemical is "packaged" may have a big impact on how it is metabolized. Drugs that are specifically marketed as chewables are prepared in such a way that it's OK for the absorption to begin in the mouth. But drugs that are prepared in capsule form, for instance, are intended to reach the stomach before absorption begins. So, as an example, if you open the capsule and sprinkle the contents on food that is then chewed and swallowed, the drug may not be absorbed properly.

Speaking of food -- this is a sidebar issue -- but I hope you've been told to always give Kimi her Vetoryl in conjunction with a full meal. This is because it needs to be absorbed in the stomach along with food in order to be metabolized efficiently.

Last but not least, a specific warning about Vetoryl is that the powder can cause skin irritation in humans. Also, women who are pregnant or can become pregnant are specifically warned to not handle the drug because it may cause birth defects if it's absorbed into the woman's body.

OK, gotta go, but I will look forward to reading more about your little girl!

Marianne

[Wuchi]

Welcome to the forum :) have you tried apple cider vinegar (use the unfiltered -- most grocery stores carry it) for the urinary tract infection UTI? A lot of dog owners have had better results with it than the antibiotics and it's a lot cheaper and has less side effects. The ACV changes the acidity in the body.

Sounds like they recommend daily for a week and then once a month for maintenance. There are a bunch of sites out there, here's one
http://www.apple-cider-vinegar-benefits.com/acv-is-perfect-for-urinary-infections-and-bladder-problems-in-dogs.html -- they usually have chat comments at the bottom of the page which comtain additional info.

You can add it to their water or in plain yogurt (can add to peanut butter -- have heard some peanut butter's have ingredients aren't good for dogs but can't find the link).

As a bonus, some articles say it can help during flea season: https://www.dogsnaturallymagazine.com/3-simple-ways-apple-cider-vinegar-can-help-your-dog/

[kimithedachshund]

Wow thanks for the warm welcome and the quick replies. Very much appreciated. I'll discuss the ACV with my vet tuesday when he's next in and will definitely follow those links and look into it as well.

As for the pill splitting issue I think I'll start a separate thread for that topic. Meanwhile, I have some of Kimi's labs with me so I'll post what I have now and should get the rest on Tuesday.

Late last summer we started noticing that Kimi was having urinary incontinence. It didn't happen often but she could be napping on the sofa with us and I'd realize she wet the sofa without even waking up. Didn't happen often so I didn't think much of it. One day on her walk in October she peed about 8 or 9 times, and then less than half an hour later peed on my lap. We dipped her urine and it was negative but we took her to the vet anyway and he saw one white blood cell on the microscope and we started her on a cycle of antibiotics and did some bloodwork october 9 2015

ALT 177 (18-121)
ALP 407 (5-160)
Platelets 522 (143-448)

He called and suggested repeat bloodwork in a month due to the elevated ALT/ALP.

Kimi was looking better and not peeing inside as much after the abx, so I neglected to follow up on the repeat liver function tests.

Early february outside of my vets opening hours I noticed Kimi was peeing pink, and instead of peeing and coming in, she was peeing like 8 or 9 times and not wanting to come in. I rushed her to a nearby open clinic (urine sample complete with red chunks in hand) and we diagnosed a UTI. They did X-rays and a quick look with U/S for stones. Since I was in a vet clinic anyways I told them about the previousy noted elevated liver enzymes and requested that they repeat them. They did a full geriatric panel but I have neither the U/A nor those labs with me. I'll include that Tuesday night after work. I can say that both the ALT and ALP were significantly higher then. Two weeks of clavaseptin and Kimis urine was clear spec. g. 1.013 Feb. 20 just prior to ending Clavaseptin.

Feb. 23 Kimi's birthday and she's peeing pink again. Back to my vet and U/A shows S.G. 1.009 leuck. 2+ Blood 4+ another 2 weeks of abx this time clavamox. Vet notices loose skin and bloaty appearance and comments that my dog looks cushinoid and with the symptoms recommends U/S and ACTH. We book an appointment for March 5 for repeat U/A and ACTH.

March 5 Kimi's urine is clear again. No UTI and S.G. of 1.010.
Having trouble getting in touch with the Vet for results for a few days after the test. Finally March 10 I decide to go down to the vets office to discuss the results and as it happens Kimi is peeing pink again. Another UTI SG 1.019 3+ Leuck, 4+ Blood, 2+ Protein. Clavamox again and ACTH results
Cortisol Pre 107 (28-120)
Cortisol Post 604 (220-550)

The vet is very reluctant to start medication prior to the U/S especially given that even though the 'post' number is out of range it's only minimally so. However with all the clinical findings as well as the slightly out of range ACTH and significant pressure from me we decided to try the Vetoryl. I'm really hoping to see an improvement in my Kimi the symptoms are no fun. As stated earlier he has prescribed 20mg once daily and so far 2 days later she's shown none of the scary side effects I've read about.

To be continued. It's late and I've got to go to bed

Thanks for reading all that. Kimi is my first pet.

[mytil]

Hi and welcome from me as well.

I have a sec but wanted to ask if you could repost the ACTH test results and include the letters after the numbers (i.e. ug/dl, nmol for example). If it is nmol just divide by 27.59 to get the results in ug/dl.


Cortisol Pre 107 (28-120)
Cortisol Post 604 (220-550)

Also, I am wondering if your vet is hesitant to start treatment because there is some confusion of the ACTH results difference between a non-Cushing's dog versus one with Cushing's. The normal level for a normal non-Cushing's dog is much different than a dog with Cushing's.

Terry

[kimithedachshund]

Ok sorry yes it's nmol/L

so dividing all these numbers by 27.59 I get

result normal

3.878 (1.015-4.349) pre
21.892 (7.974-19.935) post

[molly muffin]

If she is having constant UTI's then the first thing would be to have a culture done to make sure of what type of bacteria is causing the UTI's. Some such as ecoli (not uncommon in dogs) can be a real dickens to get rid of and require a month or more of antibiotics to completely clear it up. A culture would show what type of bacteria it is and then the corresponding antibiotic and a long enough term would be administered.

The thing about ACTH is that if she is having these constant UTI's they can affect the ACTH test and cause it to be high. That is why normally we tend to say it's better to have the ACTH done, once UTI's have been cleared up for at least a month or so. (especially reoccurring ones) At 21. post, she is not that far out of range, if at all.

That is my first thoughts.
Welcome to the forum!

[kimithedachshund]

I asked the vet if a culture was necessary and he didn't think so. He seemed convinced the bacteria is e. coli.

As for culturing the urine I'm not sure I understand why a bladder tap is the only way to obtain a suitable specimen...In humans a midstream clean catch into a sterile container is sufficient. Can't imagine doggie bacteria i all that different from human bacteria....

I might be more worried about the only slightly out range ACTH (yes slightly, not sure what you mean by if at all) if she hadn't been exhibiting every symptom I've ever read that's consistent with cushings. I mean these borderline results don't exist in a vacuum...She has bad symptoms and they seem to be worsening. If she has Cushings and the Trilostane can help her improve then that's something I can do.
If not I'm not sure where any hope for Kimi lies. The Vetoryl trial will continue for now. I'll still try to post all of Kimi's labs as I get them.

Thanks again for you interest and opinions everybody

[Renee]

I asked the vet if a culture was necessary and he didn't think so. He seemed convinced the bacteria is e. coli.

Your vet is flat wrong and is sadly misleading you. In order to determine the exact bacterial strain, and the correct antibiotic, you need a culture & sensitivity done. No other options exist. It's a crap shoot otherwise, which wastes your time and money, and even more importantly, delays the resolution of the UTI for Kimi. Sorry to be blunt, but I encourage you to over-ride your vet on this matter. Some bacteria is very strong and highly resistant. You will never eradicate the infection without proper treatment. My own pug had MRSA and required 6 weeks of doxycycline to clear it up. Without a culture & sensitivity, I would have never known.

Also, yes, the cystocentisis (sp?) is needed in order to do the culture & sensitivity properly. My pug has probably had about 20 of them. It sounds worse than it is, but it's a reality of veterinary medicine.

Even if your pup has cushings for sure (which has not been supported by a diagnostic test yet), a recurrent or unresolved UTI will cloud your ACTH results and analysis of symptoms. It is important to resolve the UTI's so that you can interpret your results clearly.

I understand your frustration with the ACTH being only slightly out of range, and therefore in the gray zone, not confirming the cushings. My pug had an ACTH result in the lower range as well (I think the post cortisol was 24). I opted to continue diagnostics and run an LDDS and later did a CT scan.

[labblab]

I asked the vet if a culture was necessary and he didn't think so. He seemed convinced the bacteria is e. coli.

As for culturing the urine I'm not sure I understand why a bladder tap is the only way to obtain a suitable specimen...In humans a midstream clean catch into a sterile container is sufficient. Can't imagine doggie bacteria i all that different from human bacteria....

Has somebody told you that a cysto is a prerequisite for a culture? I don't believe that's true, although it is probably preferred as a guarantee of sterile conditions. We've had cultures performed on urine samples obtained at home from our dogs, though, without it being a big issue.

Given the recurrent issues, I do believe I'd want a culture and sensitivity performed myself. I mean, how can your vet possibly know which bacteria is the culprit just by guessing?

Marianne

[Renee]

Ha! Marianne, we were posting at the same time!

Never had a culture done with free catch urine. Maybe this is vet specific?

[labblab]

Aha, yes, I see we were posting at the same time!

I'm guessing that a sample obtained by cysto is always preferable if possible. But if the owner is conscientious about trying to gather a clean sample at home, I would think that could still be used. We've done that for our Peg, whose mobility issues make vet visits harder to arrange these days. :o

But as you say, different vets may be more restrictive about that.

[labblab]

OK, Renee, here's a procedure page from IDEXX Labs that confirms your understanding as to why a cysto is indeed generally preferable. ;)

https://www.idexx.com/resource-library/smallanimal/urine-collection-methods-en.pdf

[Renee]

You know, for a spontaneous UTI in a dog that has not had them in the past, I would probably pass on doing a cysto the first time around ... but, when managing chronic UTI in a cushings dog, I would always opt for the cysto if possible.

That's a good procedure page from IDEXX. Always nice to have the lab protocols!

[kimithedachshund]

Regarding the Urine culture. As she is currently on abx, the culture will have to wait (not much point in culturing the urine in the middle of her current cycle). I'll make sure we do a culture if/when she next has a positive u/a.

As for the cystocentesis (if I must use the fancy term for what we call a bladder tap here in the pediatric ER where I work), I still struggle to understand why a dog requires this and a human does not. A midstream clean catch is how we do urine cultures on humans that are able to pee on command. I understand that for dogs the standard procedure when obtaining a specimen for culture is cystocenesis...my question is WHY is this necessary in dogs when we wouldn't do the same for a human. (I presume humans have a urogenital tract too)

Here are the missing abnormal labs from Feb 9.
Blood
ALP 837 (5-160)
ALT 258 (18-121)
Platelet count 563 (143-448)

Urine
dipstick
leuko. 3+
PH7
protein 3+
blood max
SG 1.015
Microscopy
WBC 2+
RBC 4+
Epithelial cells squam 1+
Bacteria Cocci 2+
Crystals Struvites rare 2

Meanwhile, my vet has provided me with a prescription so I'll be ordering compounded trilostane and he adjusted the dose to 15mg per day since this is now possible and closer to the 1mg/lb suggested starting dose.

Kimi seems to be drinking a little less but is still quite weak. I'll post more info as anything relevant comes up.

Thanks for following the story

[kimithedachshund]

Has somebody told you that a cysto is a prerequisite for a culture? I don't believe that's true, although it is probably preferred as a guarantee of sterile conditions. We've had cultures performed on urine samples obtained at home from our dogs, though, without it being a big issue.

Given the recurrent issues, I do believe I'd want a culture and sensitivity performed myself. I mean, how can your vet possibly know which bacteria is the culprit just by guessing?

Marianne

That's super cool to hear. It was one of the techs at the vet clinic that told me that for cultures they always do that. It just doesn't make sense to me. At the ER of the montreal children's hospital, children that need urine cultures who are in diapers get cathed, ones who can pee are asked for a midstream urine, and I can count on one hand the number of times we've had to 'cysto' a child in 22 years.

I plan to keep some sterile collection gear on hand, and next time she exhibits symptoms I plan to prep Kimi's 'area' with proviodine (which we don't even do for human girls), and carefully collect a clean specimen and have my vet run a culture on it. If the pattern continues should be the weekend of the 26th.

[molly muffin]

They do a cysto sometimes on Molly for a culture but more recently they just do a free catch. I prefer a free catch too.

[kimithedachshund]

Ok, so tomorrow at 2pm Kimi's going for her first (10-14 days) repeat ACTH. We'll also be repeating her U/A as tomorrow is her last dose of Clavamox.

I'm quite discouraged after 2 weeks of Trilostane. We've seen no improvement whatsoever in Kimi's condition. Still drinking a ton and weaker than ever. My friend at work said her Cushinoid Beagle showed immediate improvement with the Trilostane and I was really counting on seeing some relief for her. She falls down more than ever and her shaking has become worse. No diarrhea or vomiting, and she's still interested in her food, but she sleeps all day and looks generally unhappy.
I'll post any relevant results and comments from the vet as they come in.

Not feeling optimistic at this point.

[molly muffin]

So Kimi, normally gets her medication at around 10am? You want the test to be 4 - 6 hours after the morning dose given with medication.

Lets see what the ACTH shows. My dog definitely falls more these days, but it is because her legs sort of give out on her. Especially with the lower cortisol they feel those aches and pains a whole lot more and my molly has a luxating patella that bothers her.

Have they taken a look at her back legs for arthritis, etc?

[kimithedachshund]

Yes, Kimi's dose was given at 10am with breakfast and her blood was drawn/injection given at 2:25pm. Impatiently waiting by the phone for results. Her urine was clear again as expected but I don't have the numbers.

Hadn't considered arthritis thanks I'll bring that up when I speak to the vet.

What I find most worrisome is the shaking/trembling. Sometimes even worse than this:
https://www.youtube.com/watch?v=exz4boL500w

yesterday she seemed a little more active than usual but still drinking like crazy. Keeping my fingers crossed

[molly muffin]

Hmm, so her head actually gets the tremors. I wonder if it is some kind of arthritis or pain that the lowering cortisol has uncovered.

My dog gets the tremors and shivers sometimes. It has been mentioned as a possible side effect of medication but molly's doesn't actually look exactly like Kimi's. Did you show the vet that video?

[kimithedachshund]

Ok, so her ACTH scores were Pre 48 and post 156 nmol/L. I don't have the ranges but vet said this is right where she should be and if there were symptomatic improvement we'd be happy with these scores and stay the course.
However....
Since she's not improved at all in any of her 'seemingly cushings type' symptoms (and the vet noted that her urine was just as dilute as ever confirming my observation that she's still drinking too much), and her initial scores were borderline, we're weaning Kimi off of the Vetoryl and we have an appointment Tuesday at the veterinary hospital with an internal medicine specialist.

No signs of UTI so far. More to follow.

[Renee]

The conversion for those figures is

Baseline 1.74, post 5.65. Very much in therapeutic range.

I don't have time to post more at the moment, but I am very glad you are switching to an IMS.

[labblab]

Thanks so much for these updates, and I do agree that I think you're making the right moves. There are just a lot of question marks remaining, and I'm hopeful an IMS can offer a fresh perspective. Cushing's or not, I hope you'll stick with us to let us know what develops. We're all rooting for Kimi, that's for sure!

Marianne

[kimithedachshund]

Thanks for the continued support. I'll definitely keep updating the thread as more info comes in.

If/when we get to the bottom of all this I'll change the thread title to 'Thought Kimi had Cushings turns out it was x' in order to be more helpful to future searchers...

[Peggy Briody]

Hi and welcome. My Otis was recently diagnosed with cushings as well. Today is day 3 on vetoryl so far so good. Otis to was experiencing excessive thirst, appetite, urination, but we were lucky so far no urinary infections. He did have increased liver enzymes which now I am giving him milk thistle for his liver even the vet suggested. Hopefully Kimi does not experience any side effects of the vetoryl do have to monitor everyday. In 10 days Otis get a retest on ACTH. Hopefully you find this K9 cushings helpful I have.

[molly muffin]

Just checking in to see how Kimi is doing :)

[kimithedachshund]

Hi all and sorry for the lack of updates.

Ok. So on Tuesday March 29 we took Kimi to the Veterinary Hospital to see the IMS. She reviewed Kimi's test results and of course wanted to do an ultrasound (The only thing we haven't yet done). I told her that I have an opportunity to have a radiologist perform one in early May for roughly half the normal cost so that will wait until then. She also recommended a urine culture either 7 days after her last dose of abx or if her urine was again positive (which it ended up being surprise surprise). She also wanted sixty bucks to check my dog's blood pressure (which I found out later costs 25 at my vet's office).

However, given her clinical exam, history, and blood results, she's convinced Kimi does in fact have Cushings so it's back to Trilostane for Kimi. She adjusted the dose from 20mg once a day to 7 mg twice daily so it's compounded Trilostane (which suits me just fine given the price of Vetoryl). When I asked her for the prescription she just said that she would send it straight to the pharmacy that she deals with and has confidence in them citing that many of her patients buy their Trilostane from there with expected results. The place is Chiron out of Guelph, Ontario. Junior's Mom has written that she "Was not impressed with the quality from there at all" last year. I wonder what she meant by that? How can you judge the quality? Difference in Junior's response vs another pharmacy? Any specific Canadian compounders that people recommend?

I kind of had a feeling she's getting something back out of it... of course I have no evidence of this and I admit to being cynical and untrusting in general so who knows.

I showed her the video I posted earlier and she said it is not something that she feels is related at all to the cushings, nor has she seen this as a side effect of Trilo, or her antibiotics. She suggested a neurology consult. I can't afford to spend 175$ to have someone propose another 1000 in testing and surely the first thing would be CT to rule out a mass...

So we took her recommendations and prescription and decided to continue treatment and testing with our vet. I hate that Veterinary hospital. I'll never let anyone take my dog away from me for tests while I wait in some small room if I don't have to. At my vet's office I'm able to be with and comfort Kimi throughout anything other than surgery. Everything is more expensive there too.

While we still had some 10mg V left we were giving her 10 in the morning and 7 at night and now we just ran out so her dose just got lowered from 17 to 14mg daily so we'll do another ACTH after a few of weeks of her 14mg dose.

The UTI of course came back so as per IMS recommendation we did a culture however as promised I made a very careful clean catch and skipped the cysto. So 300 dollars later and we got a culture and sensitivity back positive for E. Coli and sensitive for exactly what my vet had her on the whole time. Remember I asked my vet if we needed to do a culture and he said naaah....it's E. Coli. We did another 10 days of Clavamox and urine stayed clear for over a week but again....

So this time we're trying 4 weeks of Clavamox and if that doesn't do it the plan is another cycle and then prophylaxis.

Overall I would say her condition is deteriorating. She has some somewhat energetic days but they're fewer and she is losing her balance and falling over more and more frequently. More accidents in the house. I have to hold her up while she's pooing so she doesn't fall on it. I keep hoping she'll get better but so far zero improvement.

That's it for now, thanks for any continued interest

[DoxieMama]

Hi, I am so sorry that you and Kimi are having such a difficult time. Am I understanding correctly, Kimi was on a 20mg once per day dose starting on March 13th with the first ACTH on March 24th. Results were Baseline 1.74, post 5.65 ug/dL. Then you "weaned her off" until taking her to the IMS on March 29th, when you started giving her a lower dose of 17mg (because you still had some 10mg pills)... and now you are reducing further to 14mg.

Why was the dose lowered on March 29th? If she has been on a newer twice daily dose since then, what about another ACTH test? I know you mentioned doing one after a few weeks at the 14mg but I'm wondering if there have been any others done beyond the first one in March. Has there been any additional bloodwork done on March 24th, or since?

Is she still trembling or shaking like in the video? Did you notice that before starting the Vetoryl or other meds?

Sorry I don't have any answers, only more questions.

Hugs from one doxie mama to another...
Shana

[kimithedachshund]

My vet's initial decision to treat with 20 mg Vetoryl came from her clinical symptoms and a borderline positive ACTH, as well as the fact that Vetoryl is not available under 10mg.
My vet was not convinced of cushings especially when her 2nd ACTH was within normal limits and her excessive drinking was unhelped by this. He was expecting some visible clinical improvement from the Vetoryl.

This is why we started weaning her off.

The IMS agreed with the cushings diagnosis citing that her UTI could be affecting her drinking, and that it could take longer to see an improvement. She said that 20mg daily was too high for my 7.5kg Kimi to start on and decided on 7mg bid to start. The 17mg was just because I didn't want to waste the Vetoryl that we already bought.

We have not had any blood tests since her 2nd ACTH, I am going to wait until she 'settles in' to her 14mg dose to re-test the ACTH. This way we can adjust the dose up or down based on evaluating her response to the IMS's actual prescribed treatment and non-Vetoryl Trilostane which is how we plan to continue treating.

Yes she's still trembling/shaking. Not constantly, but from time to time and sometimes it's worse than in the video with her teeth chattering as a result.

I'll take the hugs as long as you realize I'm Kimi's Papa, not Mama ;)
Thanks for your interest

[DoxieMama]

Vetoryl is now available in 5mg capsules, though I don't know if there's any issue with you getting them in Canada. Guess it doesn't matter since you're using compounded now, but wanted to mention it.

Be sure to watch for any adverse symptoms - lethargy, lack of appetite, vomiting, diarrhea and the like. If you note those, it is possible she may be getting too much (even of the lower dose) and I'd want to get her in for an ACTH test sooner.

Hugs for Kimi's Papa. :o
Shana

[molly muffin]

We have papas around here and mama's :) all are welcome.

e-coli can be hard to get rid of and we've seen some dogs need to be on meds for at least 30 days or more with it. While it is quite common, it is also just a bugger of stubbornness.

It is hard to see them having trouble walking and getting around. That is heart breaking for us who love them so to watch. Hopefully she will get stronger and have more good days .

No I haven't seen anyone say they can get the 5mg vetroyl in canada unfortunately.

I know a lot of vets use the pharmacy at Guelph for compounding.